l'i.Io.: PART B: read the Fact Sheet regarding Continuing Eduuatirln place my iicenge on STATUS N0 FEE I5 TO GO PRIOR TO After yea mus: $700 in go inactive. PART C: Check apprapriate statement below! .i'-'ire 3-nu r.-rum than ECI days delinquent in cnmpijring with in chi!-LI 5-tapp-:-rt cider"? If_ you are not subject to a. i:hiIr:I supgnc-rt crder. 'Hes. Fee Betore $600.00 Ftfier $Tflfi.flU PART D: RPPLICATIOMS HGT SIGNED ANDICIFE INC-DMPLEFE WILL BE RETURNED. I zrnciersranri that ii I faiaeffrauciuienl I CD1.-id lose my license. be finer: artciic-r nan-ea rather' penalties assessed. I a:-55+ er-stand the FEES ARE REFUNDABLE. Therefore. I declare that I have examined this form to the best or my imuwiecge, all starerrierat-5 are tme. correct and SOCIAL PHONE I My signature above amihcrizes the Department uf Financial and Professional Qegulaflon to reduce Ihe ciaeck it U19 amount is not correct. understand te Carri:-' if the amount sunrnirted is geatar than the required fee. but in no event shall such reduction be in an aninunt greats-r than $50. Medina! License 0361 Depanment of Financiai and Professional Regulation Division of Professinnal Regufatiun Post Uffice Bax 'rugs Springfield. IL 52791 -7986 Renewal Netices for; LICENSED PHYSICIAN LICENS Avoid Delays! RENEW the Fast and Easy Way or Dfi {See License Renewa! Instruction Sheet} MasterCard VISA DISCOVER ANTHONY JOSEPH GARCIA MD .. . - - . . Please follow the instructions below fer makina "Fm" Renewal Renewal Changes. for your Medical License. Fee Beture Fee After RE A MD Liceflii License 1fl1I Current Medical License JUSEPH $600-0? - . *1 as sakes Sunfig I. cl. tr In-ml . hadron Unfit nir- sun It:-fidd- Taial F995: PHRT A1 LICENSE RENEWHL QUESTIONS: You must real!-and to ALL of than {allowing questions in order to renew your license. Failure to answer ALL of these question will result in the l'orrn{n} boning return:-d to you for proper completion. Yes No Since July 31 . 2002. have you been convicted of any criminal offense in any state or federal court {other than minor traffic violations}? if yes. attach a statement of each conviction including date and place of conviction. nature of the offense and. if applicable. the date of discharge from any penalty imposed. I 'Yes Ei, No Since July 31. 2002. have you had or do you now have any disease or condition that impairs or impaired your ability to perform the essential functions of your profession. including any disease or condition generally regarded as chronic by the medical community. i.e. mental or emotional disease or condition; alcohol or other substance abuse; physical disease or condition? If yes, please set forth details on a separate sheet. including dates. names and addresses of treating physicians andlor counselors and nature of treatment. '(es Since July 31, 2002. have you been denied a professional license or permit. of privilege of taking an examination. or had a professional license or permit disciplined in any way by any licensing authority in Illinois or elsewhere? If yes. attach a detailed ex planation. Since July 31. 2002, have your clinical. hospital or practice privileges relating to patient care been involuntarily restricted. suspended or revoked {other than for non-completion of medical records)? If yes, attach a detailed ex planation. Medic-at License He: 035100200 Fee Before 103112000: $000.00 After 1031:2000: 5700.00 if Check (me of the following: D: 1 have Fully complied the Medtcat Education requirement of 150 SENED ANSMR BE RETURNED- aubm-tting fee atter See enctoeed CME Fact Sheet fcrfunhar understand that if i provide faisefftaudulenl information I couid tense my tnrermatier-., jrcense. be fined andtor have other penalties assessed. Ialsn understand I I ;:f1e FEES ARE NOT Therefore. I deciare that I have i 3' 0' Media' this form and, to the has: of my knowledge. statements are See anctosed CME -gtruer mrred and cornplatal I-.-nah to place my Eicense on INAETWE STATUS. No FEE IS REQUIRED TO GO PRIC-R TD After you rnust submtt $'e'flEtI _o[u5 .:-roof of CME to go inactive. SECURE-FY NUMBER ineomme PHONE NUMBER: PART C. Check appropriate statement belowdelinquent in complying with a child support order'? EIDGVE EIUWDIIZEE ':08 DE-Dfiffmfint Bf Flnanfilai and |f are nGL1_l:; a REQHEEKIOFI the not understand this wilt be done only if the amount 1'5 greater than the enquired 001 in no even: shati such reduction he made =n an amount gnaater than $50 Medical Lieenee 036100200 PIN: 001522003 License Renewal Notices LICENSED PHYSICIAN CONTROLLED SUBSTANCE Avoid Delays! Li nsethe Fa t: dE Department of Financial and Professlonai Regulation anew am as? fly i {See License Renewal Instruction Sheet] Springfield-IL W91-tfififi MasterCard VISA. orscovsn ANTHONY JOSEPH GARCIA MD Please foll Chang Renewai Renewai for your Medical License- Fee Before Fee After i License License ?l'3'i FZOBB Current Medical License ANTHONY 50359" MD . 'on, 0 Name and Address: . . . ssagis _e eisuasi as . as Controlled Substance! asaoralsa 15-on 1s.oc . i Ariel-us E. i City: State: fin C-odor Total Fees: $51 . . . . PART A: LICENSE RENEWAL QUESTIONS: You must respond to ALL. of the following questions in order to renew your license. Failure to answer ALL. of these question will result in the being returned to you for proper completion. _?Yes _l\lo I have completed the On-line Physician Profile as required for the renewal of my license. [No Since July 31, 2005. have you been convicted of any criminal offense in any state or federal court {other than minor traffic violations)? if yes, attach a statement of each conviction including data and place of conviction, nature of the offense and, if applicable, the date of discharge from any penalty imposed. _"l"es _\Alo Since July 31, 2l'.lD5. have you had or do you now have any disease or condition that impairs or impaired your ability to perform the essential functions of your profession, inciuding any disease or condition generally regarded as chronic by the medical community, i-e. (1) mental or emotional disease or condition; (2) alcohol or other substance abuse.- physical disease or condition? if yes, please set forth details on a separate sheet. including dates, names and addresses of treating physicians andior counselors and nature of treatment. No Since July 31. 2005, have you been denied a professional license or permit, or privilege of taking an examination, or had a professional license or permit disciplined in any way by any licensing authority in or elsewhere? if yes, attach a detailed explanation. Yes No Since July 31, 2005, have your clinical, hospital or practice privileges relating to patient care been involuntarily restricted, suspended or revoked (other than for nomcompletlon of medical records}? if yes, attach a detailed explanation. winEarmm Eu E. 2 _.chum. ummb mE=_n_ hmfit I fi.m._uEu oammofimo .3552 . B. F. Uw